The Cervical Spine

CHAPTER 9


The Cervical Spine


Introduction


Cervical spine manipulation (CSM) has been used for years to treat a multitude of head and neck disorders, including upper back pain, neck pain and stiffness, cervical disc problems, headaches and migraine. Practitioners of this therapy consider it a safe and effective manipulative procedure because of its relatively low adverse effects (Killinger, 2004). However, multiple recent studies have reported a range of serious and at times fatal complications following CSM, and suggested that the potential health risks associated with the procedure might offset the benefits (Di Fabio, 1999; Ernst, 2007; Leon-Sanchez, Cuetter and Ferrer, 2007; Gouveia, Castanho and Ferreira, 2009; Puentedura et al., 2012).


In contrast, some authors suggested that the incidence of serious adverse events after CSM is predictable, and might be attributed to poor knowledge of body biomechanics, inappropriate skills to use the techniques and inadequate examination and judgement by the practitioner (Refshauge et al., 2002; Haneline and Triano, 2005). Taken together, it can be said that it is of critical importance for a practitioner to have proper knowledge and appropriate skill before performing a first-line cervical manipulation.


Therefore, this chapter is written to describe the various joints of the cervical spine, the range of motion in these joints and appropriate special tests to diagnose serious pathology in the region. In addition, this chapter will also describe some of the common injuries to the cervical spine and the red flags for CSM.


Joints


The cervical spine is made up of the first seven vertebrae (C1–C7) of the spinal column, beginning just below the skull and ending just above the thoracic spine. It is divided into two functionally different segments: the superior cervical segment (O–C2) and the inferior cervical segment (C3–C7). The superior segment is highly specialised and includes the occiput (O), atlas (C1) and axis (C2). The inferior cervical segment consists of more classic vertebrae, having a body, spinous processes, laminae, pedicles and facet joints (Dodwad, Khan and An, 2014).




























Table 9.1 The joints of the cervical spine


Joint name


Description


Function


Atlanto-occipital joint (O–C1)


A synovial joint of ellipsoid variety


Forms due to articulation between the atlas and the occipital condyles


Made up of a pair of condyloid joints


Responsible for 50% of total neck flexion and extension


Serves to maintain and support the weight and movement of the head and neck


Atlantoaxial joint (C1–C2)


A complex joint consisting of three synovial joints


Forms due to articulation between the atlas and axis


Made up of a pair of plain joints (lateral joints) and a pivot joint (median joint)


Responsible for 50% of all cervical rotation


Serves to maintain and support the weight and movement of the head and neck


Lower cervical joints (C3–C7)


Originate from the inferior surface of the axis and end at the superior surface of the first thoracic vertebra (T1)


Articulations include the uncovertebral joints, disc-vertebral body and facet joints


Responsible for 50% of total neck flexion, extension and rotation


Sources: White and Panjabi (1990); Johnson (1991); Standring (2008)


Range of Motion


The cervical spine is the most mobile segment of the entire spine and supports a high degree of movement. However, movements in the cervical spine are complex, as motion in one individual joint involves not just complementary but also unequal motion between cervical levels (Van Mameren et al., 1989). In general, the range of motion of the cervical spine is three-dimensional:





















Rotation


Up to 90° (both sides)


Flexion


80° to 90° (approximately)


Extension


70° (approximately)


Lateral flexion


20° to 45° (approximately)


Source: Adapted from Swartz, Floyd and Cendoma (2005)



































Table 9.2 Range of motion between different cervical joints


Motion unit


Range of motion


O–C1


25° of flexion and extension


5° of axial rotation


7° of lateral bending


C1–C2


15° of flexion and extension


30° of axial rotation


4° or less of lateral bending


C2–C3


8° of flexion and extension


9° of rotation


10° of lateral bending


C3–C4


13° of flexion and extension


12° of rotation


10° of lateral bending


C4–C5


19° of flexion and extension


12° of rotation


10° of lateral bending


C5–C6


17° of flexion and extension


14° of rotation


8° of lateral bending


C6–C7


16° of flexion and extension


10° of rotation


7° of lateral bending


Sources: Tubbs et al. (2010, 2011); Schafer and Faye (1990)


Common Injuries


A major injury to the cervical spine is often caused by a fall or motor vehicle accident. Such injuries usually lead to a fracture in the cervical vertebra, and subsequently to pain and poor spinal functioning, depending on the severity of the injury (Torretti and Sengupta, 2007). Two of the most predominantly affected cervical levels are craniocervical junction (the junction between O and C2) and the C6–C7 segment. However, most fatal cervical injuries frequently occur at the atlantoaxial joints (Trafton, 1982).





























Table 9.3 Common injuries of the cervical joints


Injury


Characteristics


Atlanto-occipital dislocation


A highly unstable craniocervical injury that is associated with significant neurological morbidity and mortality


May occur due to severe extension or flexion at the atlanto-occipital level


Disrupts all ligamentous and/or bony connections between O and C1


Jefferson fracture


A bony fracture of the atlas caused by a compressive downward force


Causes fracture of one or both of the anterior or posterior arches


May cause fracture of all four aspects of the atlas ring


Odontoid fracture


A fracture that occurs at the base of the dens


The displacement of the fractured segment may occur anteriorly, posteriorly or laterally


Atlantoaxial subluxation


A disorder of the C1–C2 complex that impairs neck rotation


Occurs when the transverse ligament is disrupted and a rotatory component at the superior cervical segment is absent during flexion


May cause neurological injury because of cord compression between the odontoid and posterior arch of atlas


Hangman fracture


An unstable fracture caused by hyperextension of C2


Commonly occurs due to motor vehicle collisions and results in bilateral fractures through the C2 pedicles


Sources: Hall et al. (2015); Trafton (1982); Goldberg et al. (2001)


Red Flags


Red flags for CSM help practitioners to make sound clinical judgements as part of the examination process. If a red flag symptom is found in a patient, the practitioner should prioritise sound clinical reasoning and exercise utmost caution, so that the patient is not placed at risk of an undue adverse event following CSM.





























Table 9.4 Red flags for cervical spine manipulation


Condition


Signs and symptoms


Cervical myelopathy


Sensory disturbances in the hand


Intrinsic muscle wasting of hand


Clonus


Babinski sign


Hoffman’s reflex


Unsteady gait


Bladder and bowel disturbances


Inverted supinator sign


Hyperreflexia


Multisegmental sensory changes


Multisegmental weakness


Inflammatory or systemic disease


Gradual onset of symptoms


Family history


Fatigue


Temperature above 100°F


Blood pressure above 160/95 mmHg


Resting pulse above 100bpm


Resting respiration above 25bpm


Neoplastic conditions


Over 50 years of age


Previous history of cancer


Constant pain that does not subside even with rest


Unexplained weight loss


Night pain


Upper cervical ligamentous instability


Post trauma


Occipital numbness and headache


Severe limitation during the neck’s active range of motion (AROM) in every direction


Down syndrome


Other serious cervical pathology


Previous diagnosis of vertebrobasilar insufficiency


Dizziness/vertigo


Drop attacks


Ataxia


Nausea


Dysphasia


Dysarthria


Diplopia


Sources: World Health Organization (2005); Puentedura et al. (2012)


Special Tests




















Table 9.5 Special tests for assessing serious pathology in the cervical spine


Test


Procedure


Positive sign


Interpretation


Vertebral artery test


The patient is placed in either supine lying or sitting position. The examiner slowly but passively extends and/or rotates the patient’s head and neck to the maximum range of motion, keeping the patient in either supine or upright position. The examiner sustains all positions for a minimum of ten seconds while observing for symptoms associated with vertebrobasilar insufficiency.


Dizziness


Nausea and vomiting


Drop attacks


Temporary vision or hearing loss


Pins and needles


Double vision


Pallor and sweating

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Sep 17, 2017 | Posted by in MANUAL THERAPIST | Comments Off on The Cervical Spine

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